Wednesday, 18 March 2009

Continuity

Yet another post that's not clinical, isn't positive and is about management. Such is my life, at present. Ho hum!

In a previous hospital, when I was training as a psychiatrist, the Chief Executive changed. In my previous job, in the previous hospital, the Chief Exec changed. In my current job, in my current hospital, I asked about management before even entertaining the post. The Medical Director explained that the Chief Exec was a reasonable enough soul and basically let him get on and do what was sensible. He also commented that he'd seen 3 Chief Exec's since he'd been Medical Director. There have been 2 more have since he made that statement, 6 years ago.

Nurses come and go. It's necessary for their career progression. In my corner they tend to start at band 5 on the wards, then progress to a band 5 post in the community, then band 6 in a CMHT or specialist team, then band 7 as a team leader or ward manager, then they're stuck. Band 8a Modern Matrons are managers. Band 8b Nurse Consultants are managers. So it goes. To progress from band 5 to a senior role, nurses need to move around and gain experience in different arenas, so often there's turnover of staff, in a good way.

It does mean, though, that managers and nurses are coming and going at a fair rate of knots. The stability, both within the organisation and with patient care, is through the medical workforce. Senior doctors (GP partners and hospital Consultants) tend to stick around for the long haul. It's been suggested in mental health that all that's good from New Ways of Working is jettisoned and, instead, a "modular" approach is used. A care coordinator (who's re-written as some sort of journies facilitator in new CPA speak) will stick with a patient as they move through Single Point of Access, Assessment teams, Early Intervention teams, Crisis Resolution teams, Home Treatment teams, In-patient care, Rehabilitation Teams, Severe Enduring teams and so on. The fact that a patient's bounced from team to team doesn't matter - the care coordinator will remain a stable point of contact. The fact they've squillions of people to tell their tale to and no continuity doesn't matter - their care coordinator will be that continuity. The fact that each team will have a different doctor (somewhere, that's accessible some of the time, to some people) won't matter - the care coordinator will magically ensure that biomedical and psychosocial psychiatrists and GPs seemlessly deliver the same consistent care.

It's an epic work of contemporary fiction that I fully expected to see shortlisted for the Man Booker Prize. I've been disappointed. Ho hum.

The crux of it is that care coordinators come and go at frequent intervals. A band 5 CPN will be after a band 6 post. A band 6 CPN will need some experience teaching student nurses or doing CBT or undertaking nurse prescribing or managing acute care or supervising colleagues or developing management expertise so will move through posts to gain the requisite skills to then apply for a team manager or more specialist role at band 7. After time at band 7, many will look to band 8. Care coordinators are set up to fail, "navigating" the various teams and services, but equally they sure ain't providing the continuity over the long term.

Doctors can. Doctors do.

The notion of polyclinics worries many folk. Jobbing Doctor has, astutely and succinctly, narrated the zeitgeist within ivory towers and how choice is eschewed in favour of didactic This Is How It Shalt Be. Today he posts on how there will be self evident bad consequences.

It's obvious.

This perturbs me. Private healthcare can (and often is) riskier than NHS care. When my wife needed to see a Consultant, we waited a year rather than going to a private specialist. Private hospitals concern me, because I know just how scary a place they are outside of the working week. Friends work in them. The NHS does out of hours care better. The NHS has flaws, which are magnified by managers (at all levels, up to the DoH) making wholly unhelpful changes. Well, it's their job. They've got to do something.

Doctors need to be in the thick of it. We know what systems work. Folk have already said, we can sort it out on the back of an envelope over coffee in 20 minutes. Patients talk to us, day in day out. We're at the coal face. More, we're there for the long haul. For our patients, for our teams, for our organisations, doctors provide stability and continuity. It'll be a tragic day if that's lost.

I notice this sort of practice of unending layers of bureaucracy in the large IT organisation where I work as well.

It comes from the practice of Cover Your Arse (CYA) management. As a manager, you can try to either make sure things _are_ working well, or concentrate on creating reams of paperwork that protects you from when other people say that things are not working well and concentrate on that. As long as you don't give a toss about the actual outcome, and only care about perceptions and looking good, metrics and pointless surveys are just fine.

The fact that this takes time away from frontline staff getting some useful work done is neither here nor there - this stuff is generated with no regard whatsoever for your time and is all about the manager in question wanting to CYA.

The disregard for others and their time is breathtaking. They assume you will simply work late to do it all. It makes perfect sense once you realise what actually matters to the people who put it together.

All it takes is 1 person near the top to have this mentality and it will be propagated downwards, as everyone is forced to assume the CYA method. Also, over time, it becomes the norm to generate new paperwork every time there is a problem. And the further down the pyramid you are, the more layers, as each person above you simply creates their own, individual, slightly different, but different enough so you can't just copy and paste, pile of useless paperwork.

We constantly hear stuff like "good leadership comes from the top" and it's in the converse that you see this - but no-one cares. All they care about at the top is preception, screw the staff and double screw the system users (IT remember - my system users like me and my boss far more than they do my boss's boss's boss, for example).

Managers either give in, pass the stress down the line to their directs (in which case hello? why are you coming in to work at all? Managers are paid more because of those responsibilities, stop palming them off on others who did not sign up for them) or leave (which I am about to do, as the constant stress is making me ill all the time. I have been writing about this extensively on my blog but you can't see it as it's locked - since I don't want my HR dept finding it it's not freely available on the web. Once I manage to extricate myself there will be more).

Why Lake Cocytus?

Dante's "Inferno" takes us on a journey through to the deepest layer of Hell, passing down through layers of fire. Within this Ninth Layer there is no flame, there is a lake of ice. Imprisoned within this are the those of greatest evil, those of greatest betrayal. Rather a puzzle to me, this one. Is it a terrible place, manifesting evil incarnate? Or is Lake Cocytus a good thing, containing the world's greatest evils?

Good or evil this place, this Lake Cocytus, is my space to entomb the thoughts and musings best interred in ice.

"Because love is not sex or a shared faith, or the 'joint maintenance of a household and the upbringing of children'."
- Sergei Lukyanenko

"Look at that. Look at that. "Accident Blackspot"? These aren't accidents. They're throwing themselves into the road gladly. Throwing themselves into the road to escape all this hideousness."
- Withnail & I

"We know what happens to people who stay in the middle of the road. They get run down."
- Aneurin Bevan